Provider Demographics
NPI:1891983623
Name:JOHNSON, DERRICK E (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:614-224-7697
Mailing Address - Fax:614-221-5613
Practice Address - Street 1:7277 SMITHS MILL RD
Practice Address - Street 2:#250
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8195
Practice Address - Country:US
Practice Address - Phone:614-464-0162
Practice Address - Fax:614-464-0157
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-089645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2855661Medicaid
1891983623OtherNPI
OHJO7378991OtherMEDICARE